C09987540 / invoice 10000

Reason: Revisit Torn Nail FYHISTORY:Examine:PHYSICAL EXAMINATION: Mentation: alert and responsiveEYES: NAD - clear, no noted discharge #EARS: NAD - clear, no discharge, odour, erythema#NOSE: NAD - clear, no discharge, symmetrical, no lesions #ORAL: NAD - normal pink and moist mm, normal CRT, healthy teeth & gums#CARDIOVASCULAR - NAD - no murmur or arrhythmia auscultated, pulse pressures normal and synchronous#RESPIRATORY: NAD - thoracic auscultation clear sounds bilaterally, respiratory effort normal#ABDOMINAL: NAD - soft pliable, no detectable pain or palpable abnormalities#NEURO: NAD - neurologically no significant findings, no cranial nerve or proprioceptive deficits/gait#MUSCULOSKELETAL: NAD - ambulating with normal gait & posture, no pain on palpation of joints, appropriate ROM#RECTAL: not performed#REPRODUCTIVE: externally normal #INTEGUMENT: NAD - clear coat and skin #LYMPH NODES: NAD - peripheral nodes palpate normal #Assessment:Plan:GAP ONLY HISTORYFirst clinical signs - torn nail bandaging footSummary - bandage change on footDiagnosis - torn nailTreatment - bandage change and continue oral antibiotic and pain relief.--- 04/03/2026 18:30:45 SLK:Worming - Skipped on 04/03/2026    Vital Signs    

Nurse initials: CO If client didn't answerWent straight to voicemailSent sms: yes Nurse or CCT can follow: CCTCCT initials: 1 DAY FOLLOW UP CALL: Medications (names, dose & start time): Meloxicam 18kg dose SID. Noroclav 250mg 1tab BIDIs the patient eating, drinking and toileting normally? Wound concerns:Client discussion (client observations, concerns, your recommendations)Next Appt booked (due date, virtual or appointment):--- 02/03/2026 17:39:03 NB:Worming - Skipped on 02/03/2026    Vital Signs    

Reason: Split nail yesterday looking infection--- 01/03/2026 10:17:07 FY:Worming - Skipped on 01/03/2026Verified: NoSubjective:Diet: Recent changes to diet: nilPreventative healthcare:Vacc: HWP: IW: Flea/tick: HISTORY:O's presenting complaint/s: Injured nail requiring removal- Nail injury occurred yesterday- Initial bandage showed purulent discharge- Partial nail attachment causing discomfortAppetite: NormalThirst: NormalVomiting: NilDiarrhoea: NilAccess to chemicals or toxins: Nil knownAccess to rodenticides: Nil knownCurrent medications: NilPrevious medical history: Nil relevantHas insuranceExamine:PHYSICAL EXAMINATION:Mentation: alert and responsiveEYES: NAD - clear, no noted dischargeEARS: NAD - clear, no discharge, odour, erythemaNOSE: NAD - clear, no discharge, symmetrical, no lesionsORAL: NAD - normal pink and moist mm, normal CRT, healthy teeth & gumsCARDIOVASCULAR - NAD - no murmur or arrhythmia auscultated, pulse pressures normal and synchronousRESPIRATORY: NAD - thoracic auscultation clear sounds bilaterally, respiratory effort normalABDOMINAL: NAD - soft pliable, no detectable pain or palpable abnormalitiesNEURO: NAD - neurologically no significant findings, no cranial nerve or proprioceptive deficits/gaitMUSCULOSKELETAL: NAD - ambulating with normal gait & posture, no pain on palpation of joints, appropriate ROMRECTAL: not performedREPRODUCTIVE: externally normalINTEGUMENT: Partially attached nail with purulent dischargeLYMPH NODES: NAD - peripheral nodes palpate normalAssessment:Problem List:- Partially attached nail with secondary infection- Requires surgical removal under sedationTreatment:Plan:- Sedation and surgical nail removal scheduled- Post-operative bandaging- Pain relief medication- Estimate $650-700- Discharge scheduled for 3pm- Owner to be contacted when procedure complete- $400 deposit takenDiet: Preventative healthcare:Vacc:HWP:IW:Flea/tick:HISTORY:Examine:PHYSICAL EXAMINATION: Mentation: alert and responsiveBCS: ## / 9MCS: normal muscle mass #EYES: NAD - clear, no noted discharge #EARS: NAD - clear, no discharge, odour, erythema#NOSE: NAD - clear, no discharge, symmetrical, no lesions #ORAL: NAD - normal pink and moist mm, normal CRT, healthy teeth & gums#CARDIOVASCULAR - NAD - no murmur or arrhythmia auscultated, pulse pressures normal and synchronous#RESPIRATORY: NAD - thoracic auscultation clear sounds bilaterally, respiratory effort normal#ABDOMINAL: NAD - soft pliable, no detectable pain or palpable abnormalities#NEURO: NAD - neurologically no significant findings, no cranial nerve or proprioceptive deficits/gait#MUSCULOSKELETAL: NAD - ambulating with normal gait & posture, no pain on palpation of joints, appropriate ROM#RECTAL: not performed#REPRODUCTIVE: externally normal #INTEGUMENT: NAD - clear coat and skin #LYMPH NODES: NAD - peripheral nodes palpate normal #Assessment:Plan:Sedation:  given at ACPMethadone 0.4mg/kg IMMedetomidine 5-15 ug/kgMidazolam 0.1-0.3mg/kg IMButorphanol 0.1-0.2mg/kg--- 02/03/2026 17:37:20 NB:Post Surgery Follow Up - Resolved -    Vital Signs    Weight: 18.3;